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Snapshot diagnosis- Why have this woman's ankles suddenly swelled?

Ankle oedema in an older patient on amlodipine suggested the drug could be the cause – but was it? Dr Mike Wyndham describes another case from his files

Ankle oedema in an older patient on amlodipine suggested the drug could be the cause – but was it? Dr Mike Wyndham describes another case from his files

The patient

This patient is a 62-year-old lady who is a regular visitor to the surgery. She was diagnosed as having hypertension five years earlier and was prescribed amlodipine 5mg daily. She has had no problems with her treatment but has found it hard to lose the weight recommended by the practice nurse. The sudden onset of swollen ankles now compounded this disappointment. There was no major shortness of breath, although her exercise capacity was a little limited by her weight.

First instinct

One of my house jobs was working in a department of therapeutics. The professor always said that if you could only ask the patient one question it should be: ‘What medicines are you taking?' The patient was only taking one drug and that was amlodipine, an agent well recognised in causing ankle oedema. There was no obvious evidence of cardiac failure, with a normal jugular venous pressure and a clear chest.

Her abdomen felt normal and there were no swollen glands in the groin, making it unlikely that there was pathology here.

So I stopped the amlodipine and said I would review the swelling in two weeks along with her blood pressure.

Differential diagnosis

• Cardiac failure

• Hypoproteinaemia

• Gravitational oedema

• Venous insufficiency

Cardiac failure was generally ruled out from the history and examination. Hypoproteinaemia seemed unlikely as the patient was fit, eating well and had no bowel problems.

Gravity may certainly play a part in the swollen ankles of the elderly but this lady was very active.

She denied the presence of prominent veins and I certainly couldn't see any through the swelling.

The hidden clue

Nephrology was a bit of a Cinderella subject when I was at medical school, but I did recall one fact. Remember to dipstick the urine when you see swollen ankles. That was certainly an inspiration as the urine was absolutely packed with protein.

Getting on the right track

The patient had no urinary symptoms suggestive of cystitis. The level of proteinuria was strongly suggestive of nephrotic syndrome and a renal physician's biopsy a week later confirmed the diagnosis of membranous glomerulonephritis. Oral steroids were started and produced a good response with the patient going into remission.

Dr Mike Wyndham is a GP in Edgware, north London

What's caused this woman's ankles to suddenly swell? What's caused this woman's ankles to suddenly swell?

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